|
Section Name |
Field Name |
Field and/or Section Description |
|
TITLE |
|
Use ACORD 653, Policy Delivery Receipt, to obtain affirmation from the insured that the |
|
ACORD 653 (2008/04) |
Policy Delivery Receipt |
policy has been delivered and received by the insured. |
|
Name and Address of Insurance |
The name and address of Insurance Company must be inserted before this form is used. |
|
IDENTIFICATION SECTION |
Company |
Use the actual name of the company. Do not use group names. |
|
APPLICANT / INSURED |
Named Insured |
Indicate the full name of the named insured as it appears on the policy. |
|
APPLICANT / INSURED |
Policy Number |
Indicate the policy number. |
|
APPLICANT / INSURED |
Date of Delivery |
Indicate the date the policy has been delivered and received by the insured. |
|
SIGNATURE |
Signature of Named Insured |
Signature of named insured. |
|
SIGNATURE |
Producer Name (Please Print) |
Indicate the name of the producer. |
|
SIGNATURE |
Signature of Producer |
Signature of producer. |
|
National Producer Number (if |
|
|
SIGNATURE |
applicable) |
Provide the National Producer Number if applicable. |